Provider Demographics
NPI:1417378332
Name:MALONE, JACQUELINE C (LCSW)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:C
Last Name:MALONE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 5TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-5010
Mailing Address - Country:US
Mailing Address - Phone:727-873-4848
Mailing Address - Fax:
Practice Address - Street 1:100 5TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-5010
Practice Address - Country:US
Practice Address - Phone:727-873-4848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-19
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 620101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health